I recently re-read the article “Big Med,” by Atul Gawande, in which he examines the future of medical care from kitchen of the Cheesecake Factory. He marvels at the efficiency achieved by Cheesecake Factory in everything from ordering the correct amount of chicken to processing orders to teaching new recipes and dishes. They have maximized the cost-effectiveness of their business, but it was not without significant consumer research, vigilant oversight, and continued modification. What is preventing medical care from achieving similar efficiency?
The increasing importance of guidelines, protocols and algorithms in directing care is pushing medicine in a direction similar to the Cheesecake Factory. When a patient presents with a specific set of complaints, there are now measures in place that dictate the tests and studies that will yield the most likely diagnosis. A 66-year old female with burning on urination gets urine dipstick and culture, and is treated with Bactrim for a likely UTI. Similarly, a 34-year old male with Chrons disease who is 5 days post-op with fever and hypotension will be treated according to Surviving Sepsis guidelines with fluid resuscitation, blood cultures, a specific set of labs and empiric antibiotics. Both of these measures, used in drastically different situations, have been shown to reduce unnecessary testing, costs, and all while improving outcomes.
Still, physicians are hesitant to implement new protocols without seeing sufficient evidence with controlled trials. And for good reason, a patient is a person not a dish leaving the kitchen of the Cheesecake Factory. At the restaurant, we expect today’s crab cake to be the same one that we loved a week ago; patients are each different and we must consider comorbidities, insurance status, medications and allergies, and acute and past medical history. Significant increases in outcomes research to drive the development of protocols is beneficial in identifying significant steps that will maximize treatment with the impetus on improving outcomes and reducing cost, but we must remember that medicine is not a box that patients fit neatly in. We must maintain a sense of autonomy and humanism, taking each patient at face value, and not perform as robots confined to a set of tests and diagnoses.
Guidelines are just that—guides, roadmaps to improve the efficiency of care with regards to outcomes and cost. There is a time and place for the use of guidelines, but not every patient falls neatly within the circumstances in which these guidelines are meant to be implemented. For students being taught in the world or Up-to-Date, MDConsult, and AccessMedicine, we must remember that guidelines and protocols are merely starter recipes for success, but also ones that must be tailored to each patient’s taste.
The increasing importance of guidelines, protocols and algorithms in directing care is pushing medicine in a direction similar to the Cheesecake Factory. When a patient presents with a specific set of complaints, there are now measures in place that dictate the tests and studies that will yield the most likely diagnosis. A 66-year old female with burning on urination gets urine dipstick and culture, and is treated with Bactrim for a likely UTI. Similarly, a 34-year old male with Chrons disease who is 5 days post-op with fever and hypotension will be treated according to Surviving Sepsis guidelines with fluid resuscitation, blood cultures, a specific set of labs and empiric antibiotics. Both of these measures, used in drastically different situations, have been shown to reduce unnecessary testing, costs, and all while improving outcomes.
Still, physicians are hesitant to implement new protocols without seeing sufficient evidence with controlled trials. And for good reason, a patient is a person not a dish leaving the kitchen of the Cheesecake Factory. At the restaurant, we expect today’s crab cake to be the same one that we loved a week ago; patients are each different and we must consider comorbidities, insurance status, medications and allergies, and acute and past medical history. Significant increases in outcomes research to drive the development of protocols is beneficial in identifying significant steps that will maximize treatment with the impetus on improving outcomes and reducing cost, but we must remember that medicine is not a box that patients fit neatly in. We must maintain a sense of autonomy and humanism, taking each patient at face value, and not perform as robots confined to a set of tests and diagnoses.
Guidelines are just that—guides, roadmaps to improve the efficiency of care with regards to outcomes and cost. There is a time and place for the use of guidelines, but not every patient falls neatly within the circumstances in which these guidelines are meant to be implemented. For students being taught in the world or Up-to-Date, MDConsult, and AccessMedicine, we must remember that guidelines and protocols are merely starter recipes for success, but also ones that must be tailored to each patient’s taste.
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